Healthcare Provider Details

I. General information

NPI: 1295481174
Provider Name (Legal Business Name): PHYSICAL THERAPY OF WYOMING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2022
Last Update Date: 05/23/2022
Certification Date: 05/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 S DOUGLAS HWY STE 120
GILLETTE WY
82716-4949
US

IV. Provider business mailing address

1211 S DOUGLAS HWY STE 120
GILLETTE WY
82716-4949
US

V. Phone/Fax

Practice location:
  • Phone: 307-670-8111
  • Fax: 307-670-8113
Mailing address:
  • Phone: 307-670-8111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: BRANDY JOHNSON
Title or Position: OWNER
Credential: PT
Phone: 307-670-8111